Physical Frailty

Title: “Enhancing Function of Frail Elders by Modifying the Home.”
Funding Source: National Institutes of Health
Status: July 1, 1999 – May 31, 2005
Principal Investigator: Laura N. Gitlin, Ph.D.

Overview: The purpose of this study is to test the effectiveness of a home-based, client tailored, environmental modification program for functionally vulnerable older adults. The study is composed of two groups (intervention vs. control) and will enroll 318 community-living elders 70+ years of age from the waiting lists of the Philadelphia Corporation for Aging. The intervention program is designed in two phases: a 6-month active phase consisting of 5 home visits and one telephone contact, followed by a 6-month maintenance phase involving 1 home visit and three telephone contacts. It is a multifactorial intervention involving the expertise of occupational therapists, physical therapists and home modification specialists. Specific strategies that will be tested include the use of assistive devices and home alterations, energy conservation, proper body mechanics, safe fall and recovery methods, and task breakdown techniques. The specific study aims are to: 1) test the immediate and maintenance effect of intervention on functional status, self-efficacy and home safety; and 2) evaluate the cost effectiveness of the intervention to improve functional status and reduce health and human service utilization. Secondary aims will evaluate the effect of the intervention on fall rates and the prevention of depressive symptoms. All study participants will be evaluated at baseline, 6 months and 12 months.

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Title: “End of Life Decision Making about Medical Treatments”
Funding Source:Agency for Healthcare Research and Quality (AHRQ), DHHS
Status: Aug. 1, 2003 to July 31, 2005
Principal Investigator:Laraine Winter, Ph.D.

Overview: Thus study has surveyed 300 elderly men and women regarding their preferences for life-prolonging treatments in hypothetical medical situations. It brings an important decision theory, Prospect Theory, to bear in the understanding of such preferences, which are the core of advance directives. Prospect theory posits that remote prospects are more distinguishable from each other than are more immediate prospects. This leads to the prediction that currently healthier people would view worse-health scenarios as indistinguishable from death and more likely reject life-prolonging treatments, as compared with currently sicker people. This would help explain the strong preferences for medical interventions often expressed by frail elderly people, as compared to healthier.

Expected Outcomes: It is anticipated that current health status would predict preferences for life-prolonging treatments. Religious orientation, gender, and race are also expected to correlate with treatment preferences.

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Title: “Program Evaluation for Chronic Disease Self-Management with African-American Urban Elders” Harvest Health
Funding Source: Administration on Aging (AOA)
Status: Funded October 2003 – September 2006
Principal Investigator: Laura N. Gitlin, Ph.D.

Overview: This project is a cooperative effort with the Philadelphia Corporation for Aging, Center in the Park, Albert Einstein Healthcare Network, and the Center for Applied Research on Aging and Health. The object of the project is to demonstrate an evidence-based disease prevention program (the Chronic Disease Self-Management Proram, developed by Stanford Patient Education Research Center), with a target population of African-American elders. Five hundred elders will participate over three years. The goal is to enable participants to assumet a major role in managing their chronic health conditions; the objectives are to increase lifestyle skills that assist in managing chronic conditions;to increase knowledge of personal risk factors associated with chronic disease; and to increase personal responsibility in the management of chronic disease.

Expected Outcomes: It is anticipated that there will be improved health status, behavioral change, improved self-efficacy, and reduced health care utilization. A team approach to chronic disease self-management that can be replicated within the aging network w ill be demonstrated.

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Title: Research Supplements for Underrepresented Minorities: Philadelphia REACH II Initiative (Resources for Enhancing Alzheimer's Caregiver Health)
Funding Source: National Institute on Aging
Status: October 2002 to August 2004
Principal Investigator: Laura N. Gitlin, Ph.D.
Minority Investigator: Yeon Kyung Chee, Ph.D.

Overview: This two-year project involves secondary data analyses using data from the parent grant, “REACH (Resources for Enhancing Alzheimer's Caregiver Health I and II),” one of the five sites participating in the NIH-funded multi-site randomized controlled intervention trial for diverse caregivers. Treatment documentation and site-specific measures from the Philadelphia site's REACH I obtained at baseline and six months will be used to examine several interrelated research queries: the development of a model of treatment adherence to in-home behavioral interventions for managing dementia in family caregivers through multivariate analyses; the development and psychometric testing of multidimensional measures of adherence (dose, intensity, therapeutic relationships, intervention strategies, and treatment receipt and enactment); discrepancies in caregiver and provider appraisals of dementia management abilities and intervention outcomes; and the relationships between treatment adherence and four domains of caregiver and care recipient outcomes (physical and mental health, quality of life, social validity, and social significance).

Expected Outcomes: It is anticipated that the knowledge generated from these research activities will contribute to an understanding of the intervention process, which caregivers and care recipients benefit most, and the predictors of adherence to behaviorally demanding skill-building interventions.

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Title: Feasibility Phase of Farber Clinical Family Services
Funding Source: Farber Family Foundation
Status: July – December 2004
Program Director: Laura N. Gitlin, Ph.D., Director, Janice P. Burke, OTR/L, Ph.D., FAOTA, Assistant Director, Tracey Vause Earland, MS, OTR/L, Clinical Coordinator

Overview: The goal of Phase I is to evaluate the feasibility of having occupational therapy services reimbursed as an adjunct to current clinical diagnostic services provided by the Farber Institute's Clinical Alzheimer's Disease Unit. The objectives of the feasibility phase are to establish reimbursement models for occupational therapy intervention which includes caregiver education and skill-training; establish a business plan; establish integration of service with existing clinical program and administrative structure; identify referral mechanism and space configuration; and pilot test OT service model.

Expected Outcomes: It is anticipated that by the end of this feasibility phase we will have identified the mechanisms by which to obtain reimbursement for this service and the elements of the infrastructure for billing, referral, and implementation of service. At the end of this phase, we will be in a position to enter a second phase involving full implementation of the occupational therapy services (standardized assessment, home-based intervention with emphasis on caregiver education and skill-training).

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Title: Experience of Suffering in Old Age
Funding Source: National Institute on Aging
Status: 9/01/03 through 8/31/07
Principal Investigator: Helen K. Black, Ph.D.

Overview: This 4 year study, funded by the National Institute on Aging examines the experience of suffering and its relation to health, gender, and ethnicity among community dwelling elders aged 80+. This study is based on previously funded research which used the open-ended interview schedule as its primary tool. The construct of suffering refers to the experience of a profoundly difficult incident, event, or time period in life. There is a body of gerontological literature that focuses on the positive aspects of aging, yet older adults suffer from a variety of causes, such as: illness, loss, depression, pain, poverty, racism, life disappointment and family problems. Suffering may also occur due to experiences related to one's gender, ethnic background, race or religion. Respondents in our pilot research did not equate suffering with depression or pain, yet these constructs show critical linkages to the experience of suffering. This project will explore, through qualitative research, the under-studied construct of suffering. This research relates to gerontological literature that focuses on the need to reduce suffering in both clinical and non-clinical contexts. The purpose of this study is to identify patterns in elders' experiences of suffering and mechanisms of its expression.

The major aims of this research are: 1) To understand older persons' ideas and beliefs about suffering, that is, how they define suffering for themselves, and how their definition is connected to their backgrounds—their ethnicity, gender, race, and religious tradition; 2) To examine the experience of suffering for a sample of persons aged 80 and above, so we can better understand the meaning of suffering to elders in the “old-old” category; 3) To explore the effect of elders' backgrounds on the experience of suffering and, 4) To see how suffering affects mental, physical and spiritual health.

There are at least three applications to be gleaned from this research. The first is to better understand the experience and meaning of suffering in later life. Second, because findings from prior research show that most elders view suffering as different from depression and pain, it is important to understand how and why elders distinguish these constructs. Eric Cassell, who wrote extensively on the subject of suffering, suggested that the medical world should treat suffering in general, and not just “the suffering body.” This research has implications for the helping professions in regard to “suffering in general.” Third, the qualitative scientific methodology will show the importance of “narration” in research, and that to “scale” or rate suffering diminishes understanding of the personal subjective experience. Scholars who have written on the subject of suffering have emphasized narration as central to accessing the experience of suffering.

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Completed Projects

Title: "Self-Care Survey of Premier Years Membership"
Funding Source: The Senior Health Institute of Jefferson Health System
Status: Funded October 2001 - September 2002
Principal Investigator: Laura N. Gitlin, Ph.D.

Overview: The Senior Health Institute, Jefferson Health System (JHS), in collaboration with Premier Years' staff proposes to conduct a telephone survey to describe the self-care practices of a randomly selected representative sample form Premier Years membership. Premier Years is a JHS membership organization of individuals 55 years

of age or older who volunteer to join this free program. The membership program provides access to free participation in health fairs and other health events, a medication prescription plan, access to flu shots and other health related programming. Premier Years currently has close to 80,000 members who are drawn from five county areas.

The purpose of this study is twofold: 1) to help inform Premier Years staff as to how best to expand and improve services; and 2) to gain a better understanding of the basic health care practices of members from which to develop and test an innovative intervention to promote positive self-care behaviors.

Title: “A Model to Identify Frail Elders at Risk for Functional Decline”
Funding Source: Subcontract: Connelly Foundation to Tenants' Action Group Adapt Program
Status: Completed December 1999
Principal Investigator: Laura N. Gitlin, Ph.D.

Overview: This project is a cooperative effort with the Tenants' Action Group (TAG) Adapt Program for the elderly. TAG is a community organization that provides legal counseling and housing services to renters in the Philadelphia County. The TAG Adapt Program provides bathroom modifications to elder renters who are physically frail.

The purpose of this project is threefold: 1) to develop and test a screen to identify frail elders who may benefit from the added value of occupational therapy services; 2) to develop and test an assessment protocol for use in an occupational therapy consultative service; and 3) to evaluate assistive device use and its benefits for eldery renters who participate in the TAG Adapt Program.

Title: “Evaluation of Assistive Device Use by Older Rehabilitation Patients”
Funding Source: National Institute on Disability and Rehabilitation Research
Status: Completed 1996
Principal Investigator: Laura N. Gitlin, Ph.D.

Overview: This three year study, completed in 1995, examined the long-term use of assistive devices by 250 older patients discharged from rehabilitation, the feasibility of an in-home assistive device training program following hospital discharge, and described assistive device instructional approaches used by therapists in the hospital. Manuscripts have been published and others are currently in preparation that identify predictors of home device use, describe therapeutic assistive device practice, and explore long-term device use patterns.

Title: “Community Assessments Survey”
Funding Source: National Institute on Disability and Rehabilitation Research
Status: Completed
Principal Investigator: William Mann, OTR, Ph.D., University at Buffalo

Overview: This project is part of the University at Buffalo's Rehabilitation Engineering and Research Center on Assistive Technology for Older Adults with Disability, awarded to Dr. William Mann, Director, Center for Assistive Technology, Buffalo, New York.

Dr. Mann's Consumer Assessments Study (CAS) is an ongoing, longitudinal study, the purpose of which is to identify the needs of home-based older persons with disabilities and their caregivers for assistive devices. Over 500 older adults have been interviewed and additional 100 older adults are interviewed each year. The study follows older adults and assistive device use as they move from home to nursing facility.

The involvement of CHORD includes research consultation on developing a family caregiver survey, environmental assessment approaches, secondary data analysis using multivariate techniques, and manuscript development.

Title: “Life Skills Program for Individuals who are Homeless and in Shelters”
Funding Source: Philadelphia City Office of Emergency Shelter Systems –Subcontract from the Salvation Army
Status: February 1, 1998 to 2001
Principal Investigator: Kathleen Swenson-Miller, M.A., OTR/L

Overview: This project is a collaborative effort of the Salvation Army and the Department of Occupational Therapy of TJU and CHORD. The Department of Occupational Therapy is implementing a life skills program for individuals who are homeless and living in short-term shelters. The intervention involves both group and individual sessions that are tailored to the specific needs of individuals and which are designed to enhance basic life skills such as self-care, job preparation, obtaining housing. CHORD is assisting with the evaluation of the program. This is one of the first programs for which both qualitative and quantitative data is being collected in order to evaluate the success of the program as well as develop best practice models. Thus far, 76 individuals have participated in the program.

Expected Outcomes: It is anticipated that this evaluation program will yield important information about the effectiveness and costs associated with life skills training for the homeless. We seek to develop best practice models for occupational therapists working with this population and identify the most beneficial strategies for homeless men and women.

Title: “Psychological Well-being and Treatment Compliance in End-stage Renal Disease Patients”
Funding Source: National Institutes of Health
Status: Completed
Principal Investigator: Laraine Winter, Ph.D.

Overview: This research examines the dynamic process of psychological adaptation to chronic illness over time. The focus is on both psychological well-being and treatment compliance. End-stage renal disease (ESRD) patients undergoing chronic hemodialysis (HD) were chosen as the study population because of the fluctuating and unpredictable course of the illness and the problems associated with its treatment. Using a weekly diary approach and applying growth-curve data-analytic methods, the research will address some central questions about the process of psychological adaptation to chronic illness and about treatment compliance over time. Study participants are fifty ESRD patients 60 years of age or older, recruited at the University of Pennsylvania Dialysis Center. At baseline, subjects complete a battery of measures of depression, social support, functional status, illness impact, and demographic information. They complete the affect and symptom checklists once a week for six months, also during hemodialysis. Data analysis will focus on the association between mood and symptoms over time and the factors that moderate this association. The same issues will be examined for the relationship between mood and treatment compliance.